Multiple Myeloma and Anemia: What's the Link?

Written by Denise Mann
Medically Reviewed by Shruthi N, MD on February 05, 2026

 

Anemia and multiple myeloma travel together for many reasons. Marked by having too few healthy red blood cells or too little hemoglobin to carry oxygen to your body's tissues, anemia can, and often does, occur because of the myeloma disease process. You may develop anemia when you are first diagnosed with myeloma or later on. Some multiple myeloma treatments can also cause anemia.

There are many ways that multiple myeloma can cause anemia, explains Hearn Jay Cho, MD, PhD, a clinical professor of medicine (hematology and medical oncology) at the Icahn School of Medicine at Mount Sinai in New York City and the chief medical officer of the Multiple Myeloma Research Foundation. The list includes bone marrow changes, inflammation, and kidney damage. Sometimes, anemia is a result of the medications used to treat multiple myeloma.

Bone Marrow Changes

Red blood cells, white blood cells, and platelets are produced in your bone marrow. In multiple myeloma, abnormal plasma cells overpower these healthy cells. This can result in a shortage of healthy red blood cells (anemia). “Myeloma cells crowd out normal blood cells in the bone marrow and slow down production of red blood cells,” Cho says. 

Kidney Damage

Your kidneys are charged with releasing a hormone called erythropoietin that tells the bone marrow to boost production of red blood cells. When myeloma affects the kidneys, they can’t do their job, resulting in less erythropoietin, fewer red blood cells, and anemia.

“Myeloma can cause kidney failure, and kidney failure suppresses red blood cell production, which can result in anemia,” Cho explains. 

Chronic Inflammation

Multiple myeloma can also lead to anemia via the release of inflammatory proteins, says Cho. “There are a lot of inflammatory signaling molecules, such as tumor necrosis-factor alpha, that are involved in myeloma growth and expansion and suppress normal blood production.”

This is called anemia of inflammation. It occurs in people who have chronic conditions that cause inflammation, such as multiple myeloma or other types of cancer. “Treatment of the chronic disease, in general, reduces the inflammatory microenvironment in the bone marrow. Red blood cell counts will improve in that setting,” Cho says.

Up to 70% of people newly diagnosed with multiple myeloma have anemia when they first get diagnosed. Others may have anemia later in the course of the disease.

Certain myeloma treatments can increase your risk of becoming anemic:

Carfilzomib (Kyprolis)

This drug blocks the activity of proteasomes, which can be found in normal cells and cancer cells. Healthy red blood cells can be collateral damage when taking this drug, resulting in a diagnosis of anemia.

Daratumumab (Darzalex)

A monoclonal antibody that targets the CD38 protein on the surface of myeloma cells, this drug can cause blood cell counts to drop, resulting in anemia. About 45% of patients on daratumumab are anemic.

Lenalidomide (Revlimid)

This drug boosts immune activity and attacks myeloma cells. It also suppresses bone marrow function and reduces red blood cell production, causing anemia.

Pomalidomide (Pomalyst)

This multiple myeloma drug blocks bone marrow activity and lowers red blood cell counts in the process.

Iberdomide (Zenbexus)

 In clinical trials, treatment with iberdomide led to up to 28% of patients experiencing severe anemia  (Grade 3 or higher).

Normocytic normochromic anemia is the most common type of anemia in people with multiple myeloma. “Anemia is typically classified by the size and color of the red blood cells,” Cho says. “If they're too small, they're called microcytic, and if they're too big, they're called megaloblastic or macrocytic.”

Normocytic means that the red blood cells are normal-sized, but there are too few of them, says Cho. Normochromic means that the red blood cells are normal color. “Normocytic normochromic anemia means that your blood cells are the right size and the right color, but there's not enough of them,” Cho explains. This form of anemia is considered an anemia of chronic disease.

Anemia may not produce any symptoms at first, but some common anemia symptoms may include:

Anemia is often diagnosed during routine blood tests. If your doctor suspects that you have anemia, they will order certain blood tests to confirm, including a complete blood count (CBC), which measures the amount and size of your red blood cells, hemoglobin, white blood cells, and platelets. Hemoglobin is a protein in red blood cells that carries oxygen to your tissues and organs.

Anemia is diagnosed when your bloodwork shows a hemoglobin level less than 10 g/dL or a drop in your hemoglobin level 2 or more g/dL down from your normal level. In myeloma, anemia is most often caused by suppression of red blood cell production, not iron deficiency. Your doctor may order other tests, such as iron studies or kidney function, to pinpoint the exact type and cause of your anemia.

Treating the myeloma is the No. 1 way to reverse anemia, Cho says. For example, “kidney failures that are caused by myeloma can be reversible. If a patient presents with kidney failure, we start treating them. Their kidney function often improves as does anemia.”

Other treatment options include:

Red blood cell transfusion. Red blood cell transfusions help replenish your red blood cells and can provide an immediate but short-lasting benefit. Repeated transfusions may be necessary.

Erythropoiesis-stimulating agents (ESAs). Given as shots, ESAs such as epoetin alpha encourage the bone marrow to make more red blood cells. ESAs are used only when you are also on a chemotherapy drug.

Iron supplements/infusions. Your doctor may suggest taking Iron supplements to help the ESAs do their work. Ask your doctor if there are any other supplements that you should take to treat your anemia.

It's time to check in with your doctor if you are:

  • Feeling so tired that it interferes with your daily activities
  • Having trouble concentrating
  • Noticing less stamina
  • Having other symptoms of anemia, such as shortness of breath, dizziness, or a racing heartbeat

Your doctor can help find out what’s going on and whether you need treatments to boost your red blood cells.

Anemia is very common in multiple myeloma. For many people, anemia is the first symptom of multiple myeloma. In others, multiple myeloma treatment causes anemia. Anemia in multiple myeloma can be caused by bone changes, inflammation, or kidney damage. With multiple myeloma, anemia is marked by suppression of red blood cell production, not an iron deficiency. Treating the disease behind it is often the best way to replenish red blood cells.

Is anemia usually the first symptom of multiple myeloma?

“Yes, anemia is often the first symptom of multiple myeloma,” says Cho. It is typically picked up during routine blood tests before any other symptoms emerge.

Does anemia in multiple myeloma mean the cancer is worsening?

Anemia can be a sign of progression as the marrow filling with plasma cells can cause anemia, says Sagar Lonial MD, FACP, professor and chair of the Department of Hematology and Medical Oncology, the Anne and Bernard Gray family chair in cancer, and chief medical officer at Winship Cancer Institute of Emory University in Atlanta. “Anemia can also be a consequence of the treatment, which may suppress normal marrow growth,” he says. “Evaluating the anemia at the same time as disease status/response is how one can differentiate.”

Is anemia in multiple myeloma the same as iron-deficiency anemia?

No, says Lonial. “Anemia from multiple myeloma is very different from iron deficiency anemia.” There are times when both types of anemia can be present, but most often anemia in multiple myeloma is due to active myeloma or is treatment related.

 

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